Urology Coding Alert

Question: I have a urologist who did a prostate ultrasound and biopsy. After the procedure, the patient was bleeding so the urologist took him back to the operating room. With the patient under anesthesia, the urologist applied digital rectal pressure to stop bleeding. What should I code for this encounter?

South Carolina Subscriber

Answer: Report 45990 (Anorectal exam, surgical, requiring anesthesia [general, spinal or epidural], diagnostic) for the digital rectal exam and digital manual pressure applied on the prostate gland under anesthesia. Append modifier 52 (Reduced services) since the urologist did not perform the anoscopy or proctoscopy, which are both included in the 45990 code descriptor. You should also report 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) for the biopsy. Since the prostate biopsy code and the rectal examination code are not bundled, you can report both procedures without modifiers on the same day although at different encounters. Therefore, report 55700 and 45990-52 expecting full payment for the biopsy and half payment for the rectal procedure (examination under anesthesia).